2001, 03-12 Permit App: 01001396 ReroofI 1
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SPOKANE COUNTY
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PROJECT APPLICATION WORK SHEET
SPOKANE COUNTY DIVISION OF BUILDING & CODE ENFORCEMENT
1026 WEST BROADWAY AVENUE
SPOKANE, WA 99260
509-477-3675
SPECIFIC SITE INFORMATION
Street Address:
4' G= �Crtn y c'Ota
Assessor's Tax Parcel Number(s):
Legal Description:
Project Description: lob ; �g
O Building Permit
O Change in Use
O Grading
O Manufactured Home Permit
O Relocation
O Sign
O Tenant (New/Change)
O Other
OWNER/APPLICANT INFORMATION
El Indicate who should be contacted reeardinp this proiect
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0 Owner: Phone: P 7 ) 8-5-./..- 74 of—
-6-----,„e A Aryl, j Fax:
0 Applicant:
Phone:
Fax:
\ MailingAddress: /- //
/% %a. V -5c:, n n Si .6 % / cl'Z--
Mailing Address:
Main floor sq. ft.
City, State, Zip
lie vec ,--(4 c C c)./7 / y 76_27
City, State, Zip
Total habitable space
❑ I Contractor Phone
Fax
❑ Architect/Engineer
Phone
Fax
Mailing address
Mailing address
Deck sq. ft.
City, State Zip
City, State Zip
WA State Contractor license #
Contact name:
PROTECT INFORMATION
tea, ® R ''
Building height to peak
# of stories
Main floor sq. ft.
Unfinished basement sq. ft.
Dimensions
Total habitable space
2"d floor sq. ft.
Finished basement sq. ft.
Occupancy group
Construction type
Garage sq. ft.
Deck sq. ft.
.rost of project
Heat source (electric, gas, etc.)
Width:
Length:
What is the square footage of the sign
face?
How high is the sign?
Year:
Make:
# of signs
Area of existing signs
Previous address
Fire Sprinkler
Paint booth Fire Alarm
Tent
Fireworks display
Proposed use
Value
Inspectors:
Address
Inspector
Phone
O Concrete O Welding O Bolting O Reinforcement
Address
ADDITIONAL SITE INFORMATION
Are there structures on the property? O Yes O No
If yes, identify on site plan
What is the current property size?
(square feet or acres)
Is any part of the property within 250 feet of a shoreline?
If yes, ident f on site plan O Yes 0 No
What is the current use of this property?
Is your property in a designated wildlife habitat area?
0 Don't know O Yes 0 No
Will the site be served by a septic system? 0 Yes 0 No
Is any part of the property within a 100 yr flood plain?
If yes, identify on site plan
0 Maybe 0 Don't know 0 Yes 0 No
Are or will there be wells located on the property?
If yes, identify on the site plan 0 Yes 0 No
Are there any wetlands, streams or ponds within 200 feet of the
property?
If yes, identify on site plan 0 Yes 0 No
Is there evidence of fill or excavation on the property?
0 Yes 0 No
Are there slopes greater than 30% on the property? (30 ft rise in 100 ft)
(/ %) 0 Yes 0 No
Are critical or hazardous materials used or stored on site?
0 Yes 0 No
DEPARTMENT USE ONLY
Date Received:
Staff Representative:
METHOD OF PAYMENT
VISA
❑ CASH ❑ CHECK 111 :RIME D
:11C V
FAXED PERMITS WILL ONLY BE ACEPTED WITH PAYMENT OF A MAJOR CREDIT CARD
DATE: EXPIRES:
BANKCARD NUMBER:
AUTHORIZED SIGNATURE:
SUBTOTAL